Over the past six months Community Care has published a series of investigations highlighting problems in the mental health crisis care system. We have investigated bed closures, funding cuts and problems in children’s crisis care.
Last week we spoke to Dr Geraldine Strathdee, NHS England’s national clinical director for mental health, about some of the issues facing crisis services, NHS England’s plans to improve crisis care, and the chances of mental health services achieving ‘parity of esteem’ in an age of austerity…
Q: What is your assessment of the state of crisis care at the moment?
A: Crisis care is one of our greatest priorities. When we’re looking at this issue one of the first things we think about is the causes of people presenting in crisis and how we might work with partners to reduce them.
For example, employment stress is a factor in about 30% of cases where people see their GP for mental health. We’re working to support employers to sign-up to the Time to Change campaign and implement NICE guidelines on psychologically healthy employment practice. We have stunning examples nationally of organisations like British Telecom who have implemented good practice and reduced their sickness and absence bill.
Another major source of stress is people being out of employment. We’ve put in place a CCG (clinical commissioning group) outcome indicator lever to increase focus on that. We also have a lever around talking therapies so that there will be real incentives to improve access to psychological therapies…
Q: I don’t think any of our readers would question the need for early intervention work. But many people working in acute crisis care tell us they feel under an incredible amount of stress. AMHPs cannot get beds for patients, community and crisis teams are seeing budgets cut. I think they’d like to hear your thoughts on that side of things.
A: Absolutely. The preventive end is really important because that will help upstream. However, I’m very, very aware of the issues and the problems. We are fully signed-up partners to the government’s crisis care concordat. We’ve also launched, and are now working in the intensive phase, of a review of urgent and unplanned care.
Mental health has led the way in providing home-based care. We value the very high level of commitment and work that staff in crisis resolution and community teams are doing. We also know that crisis demand is rising so it is important to look at how we can reduce the pressure on those services.
One issue is that we have people accessing crisis care through 14 different access points at the moment. I think that makes it very difficult for service users and it makes it very difficult for services trying to identify where demand is greatest. We’re looking at the most effective way of mapping accessing points and then identifying ways to get people much more streamlined access.
For example, in Northumberland, Tyne and Wear they have a single access point with teletriage and telehealth staff sitting side by side. We know from international evidence that if you have well supported teletriage, you can reduce the need for face-to-face contact in crisis by around 40%. It means staff can do more crisis response by phone. They can pick up crises earlier and the service is better able to offer 24/7 crisis home treatment.
Q: Do you think crisis teams are currently delivering the intensive home treatment that they are supposed to? Data we obtained showed many teams are experiencing cuts at a time of rising demand.
A: The situation is different in different places. We need to work on the basis of information and data. So one of the things we are doing is working at pace with people in the system to map both the levels of capacity and capability and the effective interventions that exist in the different parts of our crisis pathway.
Q: Where trusts have cut crisis team or community team funding they generally say ‘we’re under pressure from commissioners to make 20% cuts’. How does NHS England respond to that? Providers feel they’re being backed into a corner.
A: I hear very different things from different trusts. I know there are a number saying ‘we won’t have a crisis/home treatment team. Instead we’ll put that crisis team function, or that assertive outreach function, into generic services’. I’d urge anyone going with that approach to really evaluate the impact.
We know from really robust research that if we want to continue the major gains that we’ve made in this country with out of hospital care, with reduced suicide above all, that there is a technology attached to the way crisis home treatment teams and assertive outreach operate. I think where people are seeing those as just functions, rather than highly skilled teams, I would really urge them very strongly to evaluate the impact.
Q: Is it not the case that a well-functioning crisis prevention system needs resources? A lot of frontline staff feel the concordat’s words are good, aspirations of ‘parity of esteem’ are good, but question how you can achieve these aims when funding isn’t being invested?
A: You’re asking the very, very difficult question that we’re all trying to answer and that is how do we provide quality care, safe care in this extremely difficult and challenging environment?
We have to look at how we can change practices. We have to look at how people in parts of the country are changing things to be able to reduce pressure on services while achieving similar quality.
We’re looking at what staff are having to spend their time doing and how it might be reduced. We can look at teletriage and telehealth as I mentioned before. We can look at the use of digital dictation to help with the administrative burden on staff. Can we introduce, as a number of areas are, digital technologies to get people more rapid access to services?
These are things that have been used in other international communities where they have economic challenges. We have to think about the method differently but I have the greatest sympathy for hardpressed frontline staff at the moment.
Q: One way staff are spending their time at the moment is sitting with distressed patients, or on the phone to hospitals, for hours and hours while they wait for a bed to become available. That is a lot of highly skilled staff who should be out doing assessments and seeing clients.
A: Absolutely, but what I would say to that is firstly can those areas get us the data? Secondly, can the services experiencing that look at areas where people have had exactly the same challenges and are trying to find their way through it?
There are areas where people are still closing beds because they’ve been able to work with commissioners to increase the capacity of liaison teams and crisis/home treatment teams. But I completely accept there will be other areas where there hasn’t been that dialogue.
Q: A recent Care Quality Commission report found that many local CCGs are failing to meet their duty under section 140 of the Mental Health Act to inform local authorities about hospitals that can be used for admissions in cases of ‘special urgency’. Should there not be a message from NHS England that CCGs should all have these policies in place and they should have been in place since the Mental Health Act came in?
Well coincidentally I was working with CQC yesterday on this and other issues related to the Mental Health Act. So, for example, there is a legal duty for people before assessing someone under the Act to where possible have section 12 doctors, at least one of whom knows the patient. I’m aware that in a third of services across the country it’s two completely new doctors. That is a practice which we would really like to see addressed.
The other thing we’re looking at is getting patients appropriate treatment. That may mean commissioned respite beds or crisis beds. It may mean home-based care. At the moment the definition of appropriate treatment under the Act is open to all sorts of interpretation and we really want to make sure that if someone is detained under the Mental Health Act that the legal requirement to get them ‘appropriate’ – i.e. evidence-based effective, NICE guidelined, least restrictive care – becomes embedded across the whole of the system in both commissioning and providing.
But there’s no specific work going on around section 140 at the moment?
There is specific work – within the capacity we’ve got in the system – going on about just about every specific issue we’ve got in mental health.
Q: Thank you very much for your time today Dr Strathdee. The reason I’ve raised some of the issues above is that we hear that a lot of staff in mental health services are finding it very, very hard at the moment. I know of good people who have left the profession because they simply feel they can’t deliver adequate care. They see the concordat, they see the commitment to parity of esteem, but it doesn’t match what they see in work every day.
A: I think the thing to say to people is thank you. Please, please don’t give up. I wish we could wave a magic wand and make parity of esteem happen next year. And please don’t honestly think people are not working as hard as they possibly can to think of every which way that we can drive changes and get good things to happen, but it is going to take time.
We didn’t suddenly not have parity of esteem in the last year. This has been there for a long time and this is the first time, certainly in my lifetime, when there has been such a commitment to improving the physical healthcare of people with mental health problems, improving the psychological care of people with physical health problems, getting people care earlier, trying to get people more home-based care.
We need all the good people we can to remain in the system and we like hearing from people. We like hearing about where good is happening because we don’t hear enough about that and I have been amazed by what I’ve seen around the country.
Watch Dr Geraldine Strathdee outline NHS England’s mental health strategy